The Neighborhood Health Hub Model: Extending Primary Care into Medically Underserved Neighborhoods to Improve Health Equity - Scorecard - MDSpire
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The Community Health Center Approach: Enhancing Primary Care Access in Underserved Areas to Foster Health Equity

  • By

  • James E. Bailey

  • Deborah O. Ogunsanmi

  • Sultan Mahmud

  • Umar Y. Kabir

  • Alexandria M. Boykins

  • Susan W. Butterworth

  • Asos Mahmood

  • Burton L. Hayes

  • Esra Ozdenerol

  • F. Maury Ballenger

  • Satya Surbhi

  • September 8, 2026

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Clinical Scorecard: The Community Health Center Approach: Enhancing Primary Care Access in Underserved Areas to Foster Health Equity

At a Glance

CategoryDetail
ConditionMedically Underserved Areas (MUAs)
Key MechanismsUtilization of health coaches and community health workers (CHWs) to improve access and management of chronic conditions.
Target PopulationLow-income populations in medically underserved areas.
Care SettingCommunity-based health and wellness hubs.

Key Highlights

  • Health coaches can improve chronic illness control and health behaviors.
  • The NHH Model addresses social determinants of health in MUAs.
  • Community engagement is essential for participation in preventive services.
  • Health hubs serve as primary healthcare providers offering billable preventive services.
  • Culturally appropriate care is delivered by health coaches from the communities served.

Guideline-Based Recommendations

Diagnosis

  • Routine screening for obesity, hypertension, and diabetes is essential.

Management

  • Implement community-based self-management services linked to primary care.

Monitoring & Follow-up

  • Track health outcomes related to chronic disease management.

Risks

  • Increased emergency department and hospital utilization due to lack of access to preventive services.

Patient & Prescribing Data

Residents of medically underserved areas with high rates of obesity and chronic conditions.

Health coaching and community health worker interventions can reduce healthcare disparities.

Clinical Best Practices

  • Utilize health coaches to enhance patient engagement and adherence.
  • Establish health hubs to provide accessible primary care services.
  • Incorporate culturally tailored interventions to improve health outcomes.

Related Resources & Content

Original Source(s)

The Neighborhood Health Hub Model: Extending Primary Care into Medically Underserved Neighborhoods to Improve Health Equity

  • by James E. Bailey, Deborah O. Ogunsanmi, Sultan Mahmud, Umar Y. Kabir, Alexandria M. Boykins, Susan W. Butterworth, Asos Mahmood, Burton L. Hayes, Esra Ozdenerol, F. Maury Ballenger, Satya Surbhi

  • September 8, 2026

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